Alarming ACL injury trend for women and junior basketball demands injury prevention protocol: Ruef and Madgen know it all too well

IT IS 4pm on a Saturday night at the Cornubia Park Sports Centre, Queensland. Mikaela Ruef stands in the middle of the court in her brand new Logan Thunder kit, ready to work.

The 6'3 American comes into the huddle with her new teammates, focused on the task at hand. And then, emotions strike her like a burst of adrenaline, and she struggles to hold it in. For 28 year old Ruef, the journey has been a long one, filled with tears, struggles and hard work; one she refers to as the longest and darkest year of her life.

For Mikaela Ruef, this shot is a second chance - a case of good things coming to those that wait.

Mikaela Ruef | Credit: Peter Burton

The buzzer sounds, and the first ball goes up in front of the faithful home crowd as this group of women take on the Mackay Meteorettes in a clash that means more than just a possible win.

This game marks her return from an anterior cruciate ligament (ACL) injury that had taken the sport she loves away for the twelve months prior, an injury that is plaguing players across the sport. Ruef reflected on this as we sat in a quiet suburban café in Springwood, Queensland.

“To be honest, I was super nervous heading into that first game,” Ruef said. “My biggest worry was that I could go out there and land funny or come down from a layup and redo that injury. Even throughout that game I was really nervous to roll into the paint, because I didn’t want to run into somebody or get blindsided.”

For her, this is putting everything on the line to prove she still has so much to offer the sport she loves. Ruef has risen from the ashes, like a phoenix reborn on the burning path of recovery, but the memory of that injury still vividly haunts her.

“I was landing and running down the court on a fast break when the point guard threw it to me in traffic, so I tried to stop and go up for a layup. As soon as my foot hit the floor, my knee just caved in as my body crumbled to the ground,” she said. “I felt it pop back into place. I thought at that point that it may have been nothing but I couldn’t walk so I knew what had happened.”

Ruef was playing in Toulouse, southwest of France back then, and opted to have surgery locally, before heading home for recovery in Dayton, Ohio, where the famous Wright brothers pioneered aviation. Just like the famous duo, Ruef was preparing herself to take flight once more.

Despite a career that has included experience in top tier leagues, including three seasons with three WNBL teams - Sydney Uni Flames, Adelaide Lightning and the Canberra Capitals – along with time in Launceston and France, Ruef knows she has much to prove with this return.

“The recovery process is never a straightforward path. It has major setbacks but when you get back, it is like ‘wow, I did all that work’ and you feel great about it. It made me a better person and really made me cherish basketball so much more being out for that long,” she added. “I just want to show everybody what I can do when I am fully healthy and my body is feeling this great.”

For Ruef, this shot in the Queensland Basketball League has been an audition for a WNBL spot – a return to the highest tier women’s league in Australia. The determination in her eyes was clear, as the focus grows like a wildfire from this chance she has been given.

Ruef now leads the state league in average rebounds (19.44) as well as total season rebounds (331). It's a skill she is proud of having stamped herself as a dominant leader in.

Another player who understands the road of recovery back from an ACL injury would be WNBL and Opal representative Tess Madgen, 28, who in March 2017 suffered a potentially career-ending knee injury.

“I was in Poland and it was the first final in the five-game series. We were playing the league’s best team in Krakow,” Madgen said. “With three minutes to go in the game I just drove in and landed with a shift pivot, and even though it felt like my leg was still moving forward, my foot stayed on the ground,” she remembered.

“As soon as I went down and felt that popping sensation I was like, ‘yeah, I have definitely done my knee.'"

Tess Madgen | Credit: FIBA

As were the thoughts of Ruef and other players who have been sidelined by this injury, Madgen’s initial reaction to the injury was bleak. The timing could not have been worse; this injury came a year after being cut from the Opals squad for the Rio Olympics.

“It was incredibly daunting, as not only did it mean I had lost my only income, but I was also overseas without any real support network. I really wanted to get back home at that time but luckily, I have great relationships around people within Basketball Australia in terms of physio and those kinds of things so that helped a lot.

“That really was the scariest thing for me. Thinking what was I going to do? Where do I begin? That’s why I became focused on recovering more quickly and getting back to the court and feeling healthy again.”

The forward would bounce back and regain her spot on the national senior basketball team, the Australian Opals, at the 2018 World Cup winning silver. She has also re-signed with the Townsville Fire in the WNBL and is now priming herself for an appearance at the Tokyo Olympics in August next year.

“It gave me fresh perspective and helped me appreciate this game in a different light. I feel that’s why I have been able to lift my game and been able to go to the World Championships and return to the Opals squad,” Madgen shares.

There aren't many physiotherapists like Victoria-based Rosanne Molloy, who are as focused and passionate around the obstacles posed by ACL injuries, especially for female athletes. Molloy has had experience with the WNBL Dandenong Rangers, the Australian Sapphires and the AIS, and discussed the real issue around this injury and its disproportionate rate of occurrence amongst female players.

“The way the female body is built, it has an increased Q-angle from their wider hips, which changes the angle to force their knees to face inward more. Factors such as the change of direction, the mechanics of their body and the landing have great impact - hyperextending for example,” Molloy detailed.

“When one of these girls is forced to pull up and change direction during play, that deceleration puts great strain on their ACL and that contributes to them sustaining this injury.”

Molloy went on to outline the recovery process for ACL patients.

“The ligament has not recovered fully until the seven month point of rehab. Because we are changing a tendon and getting it to join with a new ligament that process needs time to recover fully. Most surgeons will not let anybody do any sport-specific training until nine months. In the under 18 age group, they have a 30 per cent greater chance of re-rupture if they return to the sport before that 12-month mark. It is for this reason that it is recommended that they continue rehabilitation until 18 months.”

Both Madgen and Ruef backed up Molloy’s comments while also discussing their own personal reactions to rehab.

“It’s your career, but the sooner you rush back, the higher the chance of re-injuring it. As much as it sucked, it felt good waiting because now I feel stronger and more confident with it. For me it really came down to how it was feeling rather than an exact strict timeline – that’s the way I took my rehab process,” Ruef said.

Madgen on the other hand, talked about how her post-ACL injury scare highlighted the need to implement a program that could manage, or better, reduce the growing injury numbers.

“When I was rehabbing I got the all clear to start playing again. The night I returned to the court I injured my ankle, but really thought I had re-ruptured my ACL. I passed all the physicals but the same movement occurred and I thought I had really done it again.

“At that point, when I spoke to my surgeon he advised that unlike most other codes, basketball does not have a warm up or pre-hab routine that players could undertake to prevent these injuries - which is weird. Luckily, from having that scare I was able to take my time and after speaking with my physio, I was able to add that preventative training and warmups to my routine. I will always do that until I retire as even though it looks funny (while doing those warmups before games), I know it works for me.”

ACL injuries for women are occurring at a rate that is nine times higher compared to men, but it is surprising, even shocking when Molloy points to the largest group of sufferers.

“In the last few years, the biggest jump in patients has been the 14-to-16-year age group – they make up at least 50 per cent of my patients,” Molloy added.

“As their muscles grow, they need time for their body to catch up also. So you have these talented youngsters who are not given the opportunity to rest and are expected to play high intensity with great demands placed on them from their sport, which makes them even more vulnerable.

“Every time they grow, muscle adaptation and strength takes place and there is never time given to take that into account as they are put in a position where they are required to maintain that workload.”

It's not limited to Australia. ESPN's Baxter Holmes also recently highlighted the growing trend in a two-part feature (Part 1 | Part 2), where ACL reconstruction surgeries were being performed multiple times on young kids, stemming in part from extensive training.

This age group is the largest, accounting for more than 70 percent of entire injury rate – poses an expensive and painful health problem, which the sport’s governing body needs to address. New research has revealed that Australia has the world’s highest rate of ACL reconstruction and surgery but the injury is largely preventable.

“Good preventative programs for ACL prevention that include bio mechanically sound skills and training within pre-warm up reduce the rate of this injury by 50 per cent. Our sport does not have any program like this and this needs to change for the good of the sport,” Molloy stated.

“Netball has knee.netball, AFLW has Prep-to-Play and FIFA has FIFA11+ - but even as such a high profile sport, basketball does not have a program implemented for warmups to prevent this injury, which astounds me.

“When I was looking after the Sapphires and at an elite level, the coaches and staff are very good and proactive at good skills-based training that has components of preventative warm-ups. We would run programs such as this but that was only because we had staff who developed and supported them independently. A program needs to be created and rolled out within our communities from elite level to the grassroots.

Ruef reflected on this point as a key issue surrounding the injury.

“Basketball Australia and FIBA should have rolled out a program like this long before now. I’ve always tried to do preventative training and warm-ups but I feel I’ve become more aware of what I need to do on my own now,” she said.

“I have previously had ankle injuries and actually sat out a year with plantar fasciitis [jogger’s heel]. So since I’ve always had bad ankles, I have just gotten myself into the pattern of doing those warm-ups and training.”

Dr Peter Harcourt is a globally recognised elite sport physician who represents the CMO Basketball Australia/AFL and FIBA Medical Commission.

“Women are more susceptible to ACL injuries in sport generally, and most sports have programs, including basketball, to counter this trend, the cause of which is complex and poorly understood.”

He commented on FIBA’s stance regarding the injury as well as the progress that the governing body is taking to assist with this injury.

“Basketball Australia is guided by FIBA's recommendations produced by the FIBA Medical Commission, which currently includes good warmup of at least fifteen minutes that mimic game circumstances, coaching of technique for risk circumstances (twisting and turning, sudden changes of direction) at training as well as specific balance and strengthening at training. This is provided through various coaching professional development,” he stated.

Even though this statement is clear on the stance from the governing body it seems that the policy or routine has not been communicated to the players, coaches and support staff. Ruef and Madgen were certainly not aware, despite having experienced the injuries.

Madgen reflects on what is to come as she focuses on a tilt at gold with the Opals at Tokyo 2020. For her, this time has given her something more than just a story of injury or fightback.

“That injury and the entire recovery has really set me up for the back half of my career.”

It's 7pm. A buzzer echoes throughout Cornubia Sports Complex as the game ends. It lingers in the air like a phantom, and stays in Ruef’s head. She comes through this first match unscathed, her initial nerves subsided and a long-forgotten hunger rekindled with a 16-point, 16-rebound, 6-assist performance, on the way to an 82-62 Logan win in front of her new passionate home crowd.

It's the first step on a journey which has now seen her dominate most opposition as well as work herself into clear MVP favouritism. Day by day, Ruef is getting closer to that WNBL spot and achieving that goal. Like an athletic and competitive machine, she continues to wear away the rust from her injury – hungrier than ever and ready to play.

Basketball has been growing rapidly both on the domestic and international scene, and cautionary tales like Mikaela Ruef and Tess Madgen are only two stories among many more untold tales out there. There's no doubt better preventative measures need to be introduced, before the next generation of basketball athletes suffer in similar silence. Before more careers fade away, and become memories that echo softly as footnotes, all but forgotten in Australian basketball history.